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Brilliant. Uh Thanks everyone for joining our next session on a global surgery and frugal innovation. And it's also new that is um you know, extremely active. Um And we've got some talks from some fantastic speakers uh doing some, some really great work and working with um different communities in low middle income countries. And so, uh unfortunately, I don't know if uh due to very scheduling things, I think we've only got recorded talks for this uh for this session. Um So our first talk is from Will Bolton who is a neurosurgery trainee in the UK. And the uh ideal collaboration, global lead was involved in some of the work that James was talking about previously, but applying this to a global settings and so fantastic to, to have him sharing his experience and expertise and particularly looking at um how this can be applied in settings. And so thank you very much. Hi, everyone. I hope you're having an amazing Asset Innovation Summit 2024. It's an absolute honor to be here to talk to you as part of the global Surgery session. My name's Will Bolton and I'm the ideal global lead and I'm also a neurosurgical er registrar in Leeds and I'm academic with a global health uh phd, particularly focused on surgical technologies for low resource settings. And my email address is there. So please feel free to, to email me if you uh have any extra questions. I'm really here to talk to you about the importance of global surgery and the importance of innovation and technology to address unmet needs in global surgery. And to tell you a little bit more about what the ideal framework and ideal collaboration might be able to do to help you in achieving your innovation goals in global surgery. So just for those of you who may not be aware, global surgery is a huge academic and clinical field. And it's an extremely important one for health care across the world in general because a third of all of the global disease burden is attributed to surgical conditions and even today, 5 billion people. So five out of every seven lack access to safe, affordable surgery and this results in over 50,000 preventable deaths every single day. So a huge um unmet need. It's also an extremely costly problem as well as the the human lives and suffering loss. There's a huge global economic uh cost as well. Indeed, if we don't address this uh significant challenge by the year 2030 we'll lose 15 trillion um from the global economy who lost our output and um early lives are lost. And what type of surgery and surgical procedures. Are we really kind of focusing on and meaning when we're talking about global surgery and we, we are wanting to include all, um, operations and specialties. But really, there's these bell weather procedures which, um, every first level hospital, so every primary hospital should be able to do. And if your hospital can do these three procedures, you'll be able to address a huge chunk, probably just over three quarters of a chunk of the problem that you'll see coming through your um coming through your surgical floor. So obviously, laparostomy for general surgical conditions, um management of the long bone fractures and then Cesarean section are absolutely critical. This heat map shows you the workforce uh density and access to surgical care as a proxy. Therefore, so you can see that the darker it is the um the the lower the proportion or the higher proportion of people who don't have access. So Sub Saharan Africa and Southeast Asia are particularly dark spots where high income countries like America, Europe and Australia are relatively um uh privileged in this regard. Traditionally, surgery has been neglected. I'd say as part of the global health uh research landscape because it's been seen as being too kind of indulgent and expensive. But this graph here shows that the um surgical procedures in red bars at the top of the chart versus the traditionally thought of cost effective health interventions. So, global health and the blue bars and the second half, they overlap in terms of cost effectiveness. So things like vaccines and malaria nets are just as cost effective as things like Cesarean section, eye surgery, hydrocephalus, surgery, and so on. So it's an extremely good investment to invest in surgical care. But of course, surgery needs technology, surgery needs devices, surgical needs innovation for it to work. And how do we do this when we've got such significant resource constraints and a concept that I want you to become familiar with. I think that you'd find useful is this concept of frugal innovation. And there's a number of principles that I've mapped out in this infographic here. But um just to pick out a couple, you need to really make the most of the resources that you have available. So how can you make every single um penny or pound or whatever count when it comes to cost effectiveness? How can you make things as efficient as possible in every dimension in terms of time, in terms of resources used in terms of how long it's gonna last and so on. And you need to focus really on core functionalities. So really understand the problem and articulate it in a really simple way and understand the minimum required specification to address that problem. Try not to have anything superfluous. So only stick to the minimum functionalities, there's others there, but in the in the interest of time I'll move on. But those are some of the key principles that are related to food innovation. There's different innovation methodologies and principles and kind of concepts that I think would be really good for you to um also read around some of them are overlapping. I guess if these were in a Venn diagram, you would have some overlapping circles. And I think trying to get a nice mixture of these different types of innovation um methodologies in your process, I think is where the the sweet spot lies. So responsible innovation. This is this is where you'd consider things like sustainability and making sure everything you do is ethical and there's also this um emerging phenomenon around green innovation. So doing things in as environmentally, in a friendly way as possible, I think that it's, I think that it's fair to say that all of those concepts would be very valuable at any healthcare setting, not just a low resource environment. It's extremely important to do these things even in you, even if you're in a high income country context, reverse innovation is about identifying best practice wherever it arises. And recognizing that the best innovation may be appearing in the um most unlikely of places. So you, you know, you may be able to speak to a team that already works in a low resource environment and they might actually already have a really neat innovative fix to try and overcome the uh the problem or challenge. And you might think actually that could be adopted elsewhere um with some modifications or with some teaching. So how can we adopt the best er innovation wherever it arises? And then disruptive innovation, a disruptive innovation fundamentally alters the market. So how can you fundamentally change a process or a practice to create something that's very creative and game changing, for example. And then frugal innovation, as we've sort of touched on briefly, it's about doing more or better with less focusing on really context specific design. So will your design actually work in the context that you want it to work in? So you need to understand the environment and the setting that it's going to be working in. And of course, I'd say with any technology or innovation project involving interdisciplinary stakeholders from the different sciences, engineering, industry, policy, politics, you know, and um other healthcare professionals, all those different specialties are gonna be and, and disciplines are gonna be what's needed to make you innovation work, it makes you involve them nice and early. So Fogle innovation going into a little bit more detail. I recommend you can read this, you know, to read this book, but really it's all about trying to do more with less. As I've said, you wanna try and get this nice balance between the research or the evidence that's required to er give people the confidence that your technology or innovation is going to be um you know, the safe, effective cost, effective, the things that we need to get regulated, to get funded and to prove that we should be used in a safe way. So we need to balance that research side of things as long along with the technology side of things. So here are things like who's gonna be using it, who's the actual person that's going to be using it, who's gonna be used on or for or with what training is required to even use that intervention. Um Again, the thinking about the context, the systems and the processes that that intervention or that innovation is going to be used in, it might be wildly different to what you're used to. But global surgery is all about recognizing what you don't know, going to the place, speaking to people understanding the concept and working with them to co create the solution that's gonna fit in that setting in that context properly. And that feeds nicely into the third element of the triangle, which is collaborate again, collaborating with those key stakeholders. That's the name there. I think he's gonna be absolutely essential. So just talk about some frugal innovation case studies. I guess things that maybe think about um the, you know, why are these frugal innovations and why are they work? This first one here is called the mi, which means, you know, which is AAA mud fridge, it means clay essentially. So it's essentially a fridge that's made out of local resources. The the the actual fridge itself is made out of clay. It's got cooling shelves, it's got, uh, a container at the back where you can pour water in and it acts as a cooling, um, a cooling system for keep keeping your food fresh an extremely important, you know, me cool thing, I guess to have fresh, clean food and it's all made out of locally sourced materials. It's completely biodegradable. The only thing that's different, that's not is the perspect, um door which is actually optional. You don't need it for that. But and a really nice example of a frugal innovation. The next is a pulse oximeter from the NGO Life box which some of you may have heard of and you may recognize this. And here, what I really liked about what Life Box did is they looked at the fact that a large proportion of theaters didn't have access to a pulse oximeter. And it was the only piece of technology that was mandated on the wh O surgical safety checklist that we all do before we start an operation. So they look, they had spoke to a number of um clinicians, anesthetists and surgeons and said, what are the minimum required specifications? So what is the accuracy level, the data that it should provide? How long should it last? And they published those that core set of specifications, they published it and identified industry partners to produce this at a really affordable price and there's tens of thousands of these. Now across the world and some of them have been going for over a decade. This is a laparoscope, a single use laparoscope which actually you can reuse and you can sterilize and reuse. But it's essentially a camera on a stick called the xenos Cope. It's $85. You can now do laparoscopic surgery in the most low resource environments without an expensive stack. And finally, this is mosquito mesh, which in itself is a frugal innovation just for its purpose of trying to reduce malaria. But if you treat it with chemicals, you can repurpose it as an ab yeah, as an abdominal um hernia mesh repair device. And it's actually had a lot of non inferior, non inferiority, randomized evidence that says it's just as good as the extremely expensive er mesh that we might use. So what does all this have to do with ideal? So ideal is an evaluation and a research institute that guides us into how we can actually put some evidence behind our innovation and behind our technology and it's been around for decades now, but it's, you know, it's it's extremely well used in high income countries, particularly the United Kingdom. But as you can see by this graph during this analysis, it was comparatively not that well used in developing countries. So one of the things that we wanted to do was to go out and do a global survey to try and transfer translate some of the findings and teachings from the ideal framework into a more appli applicable framework for people working in low mid linked countries. So it starts all the way with a pre ideal stage section so that you can figure out where you are in the research journey and choose the right appropriate stage all the way through to ideal stage zero, before you start a clinical study with patients or with humans through to ideal stage one, which is your first in human study, your ideal stage two A and two B, which are the kind of more cohort or maybe feasibility RCT studies. And then on to your ideal stage three, which is looking at your traditional randomized controlled trial. Finally ending in stage four that looks at delivering registries to monitor interventions and then panage considerations to give you guidance and tools at every single stage that I think will be very useful. Um no matter where you're doing your research, but particularly if you're doing it in learn and income countries, the way it's published in this paper, it's um free for you guys to read for, for anyone to see. Um and it's published in the BMJ surgery interventions, the health technologies. And we also have an agreement with them that if you are working in a lo looking country and you use the framework to conduct a study, you can negotiate reduced or even free publication fees in the trial. So in the paper, so in the journal So II really implore you to take a look, read the paper and um contribute some, some amazing innovation in low resource settings. That's, that's all I've got time for today. But I look forward to the Q and A and to the rest of the speakers in this session. Thank you very much. Right. Thank you. So, now I'd like to introduce our next speaker, Mr Bish Karki, who's a general surgery trainee and honorary lecturer in Nepal at Trigger University. He'll be giving an example of fugal innovation practice talking about si global and frugal innovation in laparoscopic surgery. Thank you, innovation. Uh So team for the invitation. Good morning, everyone. My name is I'm a general surgeon for trainee based in Yorkshire with a special interest in transport, surgery and surgery for simulation tech. And today I would like to share with you the the journey of laps, laparoscopic appendicectomy simulation model. A global and fal innovation, laparoscopic surgery simulation training and its application in the low resource settings uh aimed at bridging gaps and building laparoscopic surgical simulation skills worldwide to start with. As an international medical graduate from Nepal, I experienced the firsthand, the lack of affordable simulation resources and significant disparities in surgical training and resources. Almost 5 billion people lack access to safe surgery, particularly in the low middle income country where a surgeon faces a critical search of affordable training tools. Existing simulation models are either too expensive or inaccessible, creating a gap in skills development and increased surgical risk. So, uh this gap and my previous experience in LM IC inspired me to create a low cost model that would meet the training needs in the low middle income country. So uh when I started as a surgical trainee alongside an role as an associate surgical simulation fellow at home, I was exposed to this advanced surgical simulation tools at the surgery center which was of course unavailable back home in Nepal. Uh During that time, II saw this amazing transformative power of surgical simulation. And and this contrast motivated me to conceptualize and develop a low cost laparoscopic appendicectomy uh simulation model. And over the years, we have um developed automated progress tracking system. And recently, uh we've also tested artificial intelligence segmentation in our lab C model. So uh laps is a product of frugal innovation, uh creating effective solutions under resource constraints by focusing on core functionalities. We've always made sure that um uh the center of this development uh is to make sure that it is a cost effective and during the development phase of the laps. So we started with taking the dimensions of the um a model uh directive from the post lap laparoscopic appendicectomy specimens and uh negative 3d moles were printed using ultimate uh P LA materials and autofusion 360 designing software following to which we injected remi so 20 silicons into the negative moles to produce the models lapsing mo mo negative mold would cost less than 3 lbs and the whole total production was under 5 lbs. So by utilizing the uh in-house 3d printed molds um and uh silicon, we significantly reduced the uh production cost uh compared to uh existing simulation models. And we uh ran the course internationally using our laps models. We have always been uh open to collaboration. So I've collaborated with the young electronics and computer engineers uh from Nepal um where I'm the honorary lecturer in engineering school. Um I've collaborated with the medical students from uh uh Nepal again to develop the um las automated progress tracking system. Um The main idea is to utilize the human resources available in the country to make the project sustainable. And you used all the resources 3D printers, negative mold products and silicons that's locally available. So the um automated progress tracking uh system, this provides a real time feedback allowing uh trainees to self assess their skills, which is very crucial in resource limited environments, especially when you are working in an isolated rural health center in Nepal. No. So if you are working in one of these um isolated hilly centers in northern Nepal or near the Himalayas, so the A A PT S architecture, it includes a thin insulated wires embedded in the laps models at the mesoappendix, appendicular artery and base of the appendix, which acts as an indicator when caught during the appendicectomy. In fact, uh in order to find the thin insulated wire, we use a discarded and uh um discarded headphone wires and then put this in the silicon moles. These wires are then further connected to the printed circuit board located at the base of the model which then connects with the microcontroller and then the microcontroller uh connects with the computer giving the real time data. So uh building up on the uh A PT S uh principle in order to move forward. So recently, we incorporated A I segmentation technology during a uh gas A global virtual hackathon A I and digital tech for global surgery. And in fact, we um won the winning grant and have further enhancing lapsing model. So the integration of the EI tech uh will allow for precise monitoring of surgical techniques, adding adaptability and refining feedback for trainees at a fraction of the cost of current solutions. So during the hackathon, what we did is we captured data sets from the surgical simulation video, leveled them using the um level box and exported gray scale uh images. So we serve as the uh model's predictive targets. We augmented the data set to increase its number and use it to train our A model. Uh The main aim uh towards the developing segmentation is is for the adaptive learning paths and uh predictive analytics, enhanced monitoring and A I integration propels laps to the forefront of the laparoscopic surgical simulation education technology. We're very proud that laps impact has been recognized through several awards, validating our mission to make surgical training accessible globally. This recognition highlight innovation, applicability in the low middle income country and technological integration and validates las impact and potential as an affordable accessible solution for the uh size of training in low middle income country labs model and A PT S has been tested with Chinese in the low middle income country. And feedback shows that users find the system valuable for the uh skill assessment and improvement. With high satisfaction report reported across the training sessions. We recently uh run the laparoscopy course in Nepal last January using our lapsing uh model. So the feedback uh from there was more than of more, almost more than 90% participants agreed to the fact that they, they were able to understand these steps uh involved more confident with laparoscopic upon masectomy after the course and they fail, the course was relevant uh relevant and 90% of the participants for Leo was able to meet their learning objectives regarding um left ci segmentation results. As you can see on the far right, we use um the unit architecture to train our model, the average IU score um of our model prediction is near to 90% not 0.874 to be precise, validating the potential of houses, which means better skill acquisition and fewer errors. Uh when surgeons perform live operations. In order to um further our mission, we establish and inspire global innovations in Nepal, aiming to foster global and frugal innovations in low middle income country. As part of this report, uh we are proposing the formation of the global surgical simulation network to connect um educators, innovators and trainees worldwide with an aim to share resources, knowledge and best practices and innovate collectively to improve surgical simulation training globally. I'm also spearheading International Surgical Skills Simulation course uh using our LAPS model at the uh Coronal Academy of Health Sciences in Jim Neal, one of the most remote uh medical schools situated at an altitude of uh 2500 m. Uh In fact, I might be boarding my flight uh during this session time. So a frugal innovation does not require extensive resource and it requires purpose, collaboration and creativity laps shows how even a simple resource or conscience ideas can make an impact. So I encourage each of you to embrace this mindset and join us in making surgical training accessible for all we're seeking partnership to continue refining our model and expand its use. Uh Together we can close the search pertaining gaps and empower surgeons to deliver needed safe and effective care. And of course, what's the space for lap CVR? And like I said, I'll be boarding the flight today. So I apologize if I'm unable to answer your question immediately. However, I'm eager to collaborate and I will be able to answer question and connect after the trip. So thank you everyone and enjoy the rest of the Innovation Summit. Brilliant. Uh Yes. And unfortunately, um he, he is in the middle of like at the moment. So unfortunately, isn't able to join for questions. Uh So we will move on to our next speaker instead. Um So we have a no a y who is a general surgery trainee and an executive member at Innovation for Global Surgery, uh International Group. Um, and delighted for him to be able to share his work on Gasless laparoscopy and thank you very much. Hi, everyone. It's a great pleasure to speak at the Asset Innovation Summit in this global and Frugal Innovation section. I will be discussing about gasless laparoscopy and work carried out by our group at University of Leeds for the last six years. In my talk, I will introduce gasless laparoscopy and show evidence we have generated to support this technology. The central theme of this project has been to increase surgical capacity by training of rural surgeons in this technology where a specific need has been identified. Finally, I'll share some of our dissemination, implementation strategies and scale up of this technology from a small project to a global audience who showed their interest in this technology in gas laparoscopy. The surgeon makes a small cut around the umbilicus and inserts a single helix spiral metallic device to lift the abnormal wall and create working space in places where open surgery is a standard approach. Guess as laparoscopy could potentially act as a bridge to commence a laparoscopy because of the benefits as where carbon dioxide is not required. The procedure can be performed under spinal anesthesia. It's easy to provide training with simple resources and instruments and the recovery time is much faster for the patients. This landmark paper that was published in 2020 was a non infer study comparing gasless laparoscopy to conventional laparoscopy for 100 patients undergoing appendicectomy and cholest. As demonstrated, there was no significant difference observed in the outcomes. The interoperative vitals were relatively better in gasless laparoscopy, postoperative pain was slightly high in the gasless group. Although patients did not require any additional analgesia. This was a systematic review that we conducted for around 63 studies comparing gasless to conventional laparoscopy and gasless to open surgery. This showed that the outcomes are better for gynecological procedures and there is no difference in the overall complications in either of groups. And this again supported the gasless laparoscopy as a technology for limited resource settings. The project started by a three day training program that was held in a tertiary hospital in Kolkota Medical College in March 2019. The training was delivered using the fundamentals of laparoscopic skills and the competency of the abdominal lift device was assessed using the OS A score and the laparoscopic skills were used using the goal score during live surgery. A structured training program in gasless laparoscopy improves overall knowledge and skill acquisition in laparoscopic surgery for rural surgeons of Northeast India and delivering a training program in gasless laparoscopy for rural surgeon is feasible was one of our outcomes from this study. So this picture shows in the front row, the rural surgeons who came from northeastern part of India where they work as the only rural surgeon in their health care facility. The training was delivered by surgeons from tertiary hospitals in India as well as the United Kingdom. The fundamentals of laparoscopic surgery tasks include uh five different tasks. Uh The PEC transfer precision cutting endo loop ligation, intraop extra and not tying can see the pre training and post training scores for each task as well as overall schools. There was a significant improvement in most of the tasks for surgeon over a three day period. So following the training program, we conducted proctorship in the rural healthcare facilities of the surgeons where they get to work with their team in their health facilities with the harsh constraints and limitations that they experience on a daily basis. It was important for us to see how the technology would work in the setting that it was made for. And it was great to see our rural surgeons who were initially trained several months ago in gasless laparoscopy who were performing these procedures independently with their staff. Following the training and proctorship, the outcomes of the procedures performed by rural surgeons of Northeast India were captured through a registry and the results were striking where 50% of the procedures were performed under spinal anesthesia. The majority of the procedures were cholest appendicectomy and tubal ligation where patients were discharged on day three after, after the surgery and the complication rates of 5.7% the learning comfortable ligation was relatively shorter, but cholecystectomy was taking much longer compared to previously published data or the study that we performed in New Delhi. But given the circumstances and the limited resources, the early phases of the study, a longer operative time or something that we did anticipate. However, the conversion rates were relatively lower in these patients. This study shows that the scale up of the provision of laparoscopic surgery through increased provision of gasless laparoscopy would reduce the cost burden to patients which is shown in panel A and increase the number of dallies averted in which is shown in panel B based on a sample size of 12 healthcare facilities in rural Northeast India. If the scale up of the provision of gasless laparoscopy was achieved to a level where all surgeries were app and for laparoscopic surgery were performed as such rather than the open surgery, which is the current trend. 64% of the D is related to surgery in this patient group alone could be averted. Moreover, we developed a newer version of the abdominal wall lift device called the RA device based on the end user requirements. It has gone through a series of it situations and has finally entered the market at around $1000. This is how the raise device looks and uh it's packed in this box on your left of the screen, uh which is completely autoclavable, which is great uh to have a device that can be easily transported. So this brief video shows a rural surgeon who was initially trained as part of the target training program. Now he is delivering training the trainer program for other rural surgeons in northeast India set to use and uh very happy started from the uh to the end for that, I was I was involved with the rest. And moreover from India, the translation of gasless laparoscopy has gone to Sub Saharan Africa and the training program has now taken place in parts of Kenya Uganda. Um using the target training program that was delivered several years ago in different parts of India, we have now been able to use the platform proxim to remotely train rural surgeons from Kenya, from county. As you can see over here over here myself and Pete uh who is the engineer and one of the students. We are based at University of Leeds and training surgeons using this cloud based platform, how to set up there. Hi to everybody on Zoom and also to I've recently written from Nairobi where we organized a workshop for seven county surgeons from parts of Nairobi who were interested in becoming the trainers in gasless laparoscopy. The program was established as a collaborative project between Proximate a company called as well as the Surgical Society of Kenya to deliver sustainable training solutions in laparoscopic surgery for rural surgeons of Kenya. This is an exciting project and we're really looking forward to a lasting impact of this training program for the surgeons who are in training. So in conclusion, the key to success of a project has been collaboration, collaboration, not just with surgeons but industry partners, engineers and innovators who have identified the need and recognize the importance of this innovation. It's also important to identify the key champions, the end users who are going to use this device and through special communication channels, we have to um identify these channels and communicate the innovations accordingly uh by developing effective dissemination strategies and also working with groups, surgical groups and organizations that develop curriculum for rural surgeons. And as a group, I think we have to focus on the universal health coverage or even should I say universal health of surgical coverage so that technologies like these and many of those are accessible to everyone as well as they help to alleviate the poverty. Thank you very much for your attention and please do not hesitate to contact me if you have any questions. Fantastic. Um So that's all we talk from our er sessions. Unfortunately, we had planned a a planned discussion but as as I've said, uh unfortunately, none of these to be able to, to join us live for that. Um, so I guess all this says, I guess it's, um, hopefully a good showcase of, um, you know, things you can, you can apply in, um, you know, not just, um, setting sort of outside the UK, but actually a lot of relevant information for, um, people wanting to conduct frugal innovation within the UK and Ireland as well. Um, I think it's certainly the, the kind of global ideal framework that's online already. Uh And you've got some two great case studies of um some fantastic work conducted low middle income countries. Um Certainly if anyone is here online and is uh doing that sort of work, um Please do get in touch and we will be running this again next year. So, um if you are looking to be showcased and, and uh share your work online with us next year, I think we'd be delighted to hear um any thoughts from, from you before we move on. No, I mean, I agree. It's a fantastic showcase of what's been done around the world. And I think it's very easy for us to become comfortable with the equipment and the methods in which we do things, but it, so it's really nice to see alternatives actually. Thank you. Right. Um So we're a wee bit of ahead of schedule, so we'll have a slightly longer break. Um And then we'll be moving into the abstract session. So um great to see everyone there